Adaptive Disclosure

1. Introduction

Version followed: the 8-session, 90-minute Adaptive Disclosure (AD) manual of Litz, Lebowitz, Gray & Nash (Adaptive Disclosure: A New Treatment for Military Trauma, Loss, and Moral Injury, Guilford, 2016; cited by the developers as 2017), as its structure appears in the Marine non-inferiority trial protocol (NCT01628718), the published trial report (Litz et al., 2021, Psychiatry Research) and the developers' 2022 review. Sources: the chapter list is taken from the publisher's contents page; session number, length and frequency, the narrative's purpose, the themes of the loss and moral-authority dialogues, the homework focus, and therapist supervision and fidelity checks come from the published 2021 trial paper and its DoD final report. The manual text, its reproducible forms and the AD-E journal supplement are not drawn on, so items only they would settle stay marked [uncertain]: exposure minutes per session, impact-statement content, the complex-trauma chapter (ch. 10), the calming appendix (appendix 3) and the AD-MIL skills modules. Detailed steps for the moral-authority dialogue come from the precursor eight-step moral repair model (Litz et al., 2009). Two later variants are covered and labelled where they differ: the 12-session Adaptive Disclosure-Enhanced (AD-E) (Litz et al., 2024) and AD for Moral Injury and Loss (AD-MIL) (NCT03056157). The original 6-session version was used in the pilot (Gray et al., 2012).

Adaptive Disclosure is a brief, manualised, emotion-focused psychotherapy that Brett Litz and colleagues developed for active-duty service members and veterans with war-zone trauma. The first trials ran with Marines and Sailors at Camp Pendleton and Naval Medical Center San Diego. It mixes cognitive-behavioural and Gestalt-derived experiential methods. It combines a Prolonged Exposure-style imaginal processing strategy, CPT-derived cognitive techniques, and Gestalt-style imagined dialogues aimed at loss and moral injury [source: DTIC progress reports ADA555048, ADA612065; Darnell et al., 2022]. The name was chosen to be neutral, to lower stigma [source: health.mil 2026 evidence brief].

Core idea of change. War trauma comes in three kinds: life threat (fear-based), traumatic loss, and moral injury, meaning acts done, failed to prevent, or witnessed that violate deeply held moral beliefs. Each needs a different corrective experience [source: Darnell et al., 2022; TraumaPsychNews review, 2018; Litz CDP 2025 outline]. Full, emotionally live disclosure of the most pressing memory, done in the presence of an accepting therapist, disconfirms the expectation that remembering and telling will lead to losing control or to condemnation. It also brings unspoken meanings and implications into view so they can be revised while the emotion is active. In vivo, experiential and reparative experiences supply what fear extinction cannot: grief work with the lost person, forgiveness and repair for moral injury, and reconnection with people and roles. Fear extinction is a goal only for purely life-threat trauma [source: Darnell et al., 2022; NCT01628718; Litz et al., 2009]. The developers describe treatment as planting healing seeds and starting a longer process, not delivering a curative dose [source: TraumaPsychNews review of the manual; Litz StrongStar slides].

2. Framework

Format. Individual, face-to-face, 90-minute sessions. AD was designed as 6 sessions (the pilot used six 90-minute sessions) and was expanded to 8 for the Marine trial to match CPT-C's treatment hours. The trial protocol scheduled sessions twice weekly for weeks 1 to 4, then weekly, with up to 2 extra weeks allowed; the published trial report describes eight weekly 90-minute sessions. Where the two differ, either schedule is defensible [source: NCT01628718; Litz et al., 2021; Gray et al., 2012 summary]. AD-E uses up to 12 weekly 90-minute sessions completed within 16 weeks. AD-MIL uses 12 weekly 90-minute sessions [source: Litz et al., 2024; NCT03056157]. Trial therapists were doctoral or post-doctoral psychologists. They trained by reading the manual, had their first cases closely supervised and audio-reviewed, and received weekly hour-long supervision from AD experts. Independent raters, including the developer, scored session recordings for adherence and competence [source: NCT01628718; Litz et al., 2021; DTIC AD1105420; Litz et al., 2024].

Phase A: Assessment, conceptualisation and Session 1.

Goals: understand current functioning and the change the person wants. Compare who they were before deployment with who they are now. Identify the most pressing traumatic event and classify it as mainly life threat, loss or moral injury. Explain combat and operational stress injury and the AD rationale. Clarify goals with motivational interviewing. Assign the impact statement [source: NCT01628718; book contents, chs. 5–6; TraumaPsychNews review].
Move on when: there is an agreed target event, an agreed harm category, a shared rationale, and goals. [synthesis: no published criteria for this step are drawn on]

Phase B: Active treatment, Sessions 2–7 (exposure-based activation, identification and processing). Each session follows the same order:

Review the week and the impact statement.
Imaginal emotional processing (the trauma narrative) of the target event.
Process the appraisals, meanings and implications that surfaced.
Session review, with grounding or relaxation if needed.
A breakout component as appropriate. The grief breakout covers education, an empty-chair dialogue with the deceased, and ways to honour the dead. The moral injury breakout covers education, an empty-chair dialogue with a moral authority, and ways to make amends or move on.

Homework is behavioural: exposure to avoided stimuli, honouring activities, or reparative acts [source: NCT01628718; book contents, chs. 7–8; Darnell et al., 2022]. The published trial report describes it as corrective healing and repair assignments, such as giving back and making amends [source: Litz et al., 2021]. In the shorter 6-session framing, sessions 2 to 5 are processing sessions [source: Darnell et al., 2022]. Breakouts are optional and are chosen by harm type [source: Darnell et al., 2022]. In the precursor model, imaginal exposure is used every session at first. It is then shortened once the patient can reach the meanings without a full reliving [source: Litz et al., 2009].

Move on (from exposure to breakout, or to ending) when: the core meanings of the event have been reached and worked on, and the person can disclose the event fully without catastrophic outcome [uncertain: the manual's explicit criteria are unverified; this is inferred from the stated purposes]. The 2021 trial authors recommend measurement-based care: rate PTSD and depression before every session, and decide with the patient when to shift focus [source: Litz et al., 2021]. Use those ratings alongside the signs above when deciding to move on [synthesis].

Phase C: Ending and planning for the future (final session).

Goals: review progress and lessons learned. Identify areas for continued work (triggers, self-care, social reattachment and re-engagement). Anticipate setbacks. Close treatment [source: NCT01628718; Darnell et al., 2022; Litz et al., 2009, step 8].

Variant: AD-E (12 sessions). A compassion-history assessment in session 1 guides planning, including choosing behaviours to reclaim and a compassionate moral authority. Loving-kindness meditation and mindfulness are introduced in session 1 and run throughout. Serial letters are assigned between most of sessions 2 to 10 (the review says sessions 4 and 9 are skipped) and are read aloud in session. Imaginal dialogues develop across sessions. A collaboratively built Healing and Repair Plan sets the between-session work. The final session reviews changes in compassion. Change agents are sequenced by shared decision-making, not in a fixed order [source: Litz et al., 2024; Darnell et al., 2022]. AD-E was created because the fixed serial order of change agents often led to failure or dropout in patients who had difficulty complying [source: Darnell et al., 2022].

Variant: AD-MIL. It adds skills training and behavioural contracting aimed at obstacles to occupational, relationship and family roles [source: NCT03056157].

Readiness and screening. Trial exclusions:

serious suicidal or homicidal ideation needing urgent care (within 3 months in the Marine trial);
substance use disorder: untreated or current moderate-to-severe use excluded (the 2021 trial admitted people already in treatment and able to engage; 6 weeks of sobriety allowed entry in AD-MIL);
psychotic or bipolar disorders;
cognitive impairment or TBI that would interfere with participation;
concurrent trauma-focused or trauma-disclosure therapy, and (in the 2021 trial) past CPT.

Medication had to be stable for 6 weeks [source: NCT01628718; NCT03056157; Litz et al., 2024; Litz et al., 2021]. The manual has a chapter titled 'Using Adaptive Disclosure when Prior Complex Trauma is Present' (ch. 10; title verified on the publisher's contents page). None of the trial papers, DoD reports or reviews used here describe its content [uncertain].

3. Guiding principles

The manual's chapter 4 lists the principles; its wording is [uncertain]. The principles below are the ones stated in the trial, review and training sources.

Match the corrective experience to the harm type. Fear, loss and moral injury each call for a different change process, so classify the event before choosing tools [source: Darnell et al., 2022; TraumaPsychNews review].
Plant seeds, plan for the long haul. Treat 6 to 8 sessions as a start, not a cure. Always end with a long-term plan [source: TraumaPsychNews review; Litz StrongStar slides; Litz et al., 2009].
Fear extinction is not the main goal except for pure life threat. Use exposure to bring up emotion and meaning, not to habituate. In the precursor model, focused emotional reliving is the precondition for change [source: Darnell et al., 2022; Litz et al., 2009].
Disclosure is graded and the patient sets the pace. Do not expect full disclosure at once. Encourage full engagement but respect the limits the person sets [source: Darnell et al., 2022; NCT01628718].
Work on meaning while the emotion is live. Process thoughts during high emotional intensity rather than waiting for arousal to fall, unlike PE and CPT [source: Darnell et al., 2022].
Experiential over persuasive ("yes, and" not "yes, but"). Validate the real responsibility, then add compassion and a route to repair, instead of arguing guilt away [source: Litz StrongStar slides; Litz et al., 2024].
Do not rush to relieve guilt. Moral emotions show an intact conscience. Reassurance cannot erase real blameworthiness, and the authors write that therapists are "often too eager to relieve guilt" [source: Litz et al., 2009, p. 703; Litz StrongStar slides].
Separate the person from the act. Help the person accept an imperfect self without condoning the act [source: Litz et al., 2009].
Accommodate without over-accommodating. The aim is neither denying the event nor letting it define the whole self [source: Litz et al., 2009].
Unconditional acceptance, and therapist self-preparation. Visible disgust, fear or detachment will be read as condemnation. Before starting, rehearse in your mind the acts you may hear about and examine your own reactions [source: Litz et al., 2009, pp. 702–703].
Sober but hopeful, evocative, emotion-focused tone [source: NCT01628718].
Military-culture competence. Know the warrior ethos and mission diversity. The manual gives this a chapter and an appendix [source: book contents, ch. 3 and appendix 1; TraumaPsychNews review].
Function and roles are the target. Aim for a return to work, family and community roles. The developers frame this as fitting the military value of service [source: Darnell et al., 2022; Litz et al., 2024].
Approach, not withdrawal. Shame drives hiding. Encourage opposite action and corrective contact with people [source: Litz et al., 2009].
Repair, not righting. Amends means living differently from now on, because undoing the wrong is usually impossible. "Draw a firm line around the past" [source: Litz et al., 2009, p. 704].
Shared decisions and flexibility (AD-E). Choose and sequence change agents by patient preference and the likelihood of success [source: Litz et al., 2024; Darnell et al., 2022].
Memories as the person's experience. Process the event as the person remembers it. Do not use the dialogues to establish or "recover" facts [synthesis, per house rule].

4. Intervention inventory

Sources: NCT01628718 protocol; Darnell et al. (2022); Litz et al. (2009); Litz et al. (2024); Litz StrongStar slides; book table of contents. The manual's own session scripts, its appendix on the meaning and implications of key events, and its appendix on calming techniques are not reproduced here [uncertain]. Where a step comes only from the precursor 2009 model, or from AD-E, it is labelled. All example language is illustrative.

4.1 Assessment and case conceptualisation (harm-type classification)

Purpose / when: Before Session 1, or within it. Selects the target event and the change process to use [source: book ch. 5 title; TraumaPsychNews review; health.mil 2026].
Steps:
1. Assess current symptoms and functioning, and screen against the readiness criteria in section 2.
2. Elicit the person's deployment experiences broadly. Then identify the memory that is currently most pressing (most intrusive, most avoided, or most shame-laden).
3. Classify the target as mainly life threat, traumatic loss or moral injury (perpetration, failing to prevent, witnessing, or betrayal). Note when more than one applies.
4. Write a short formulation: what the event means to the person now, what they avoid, and which roles have been damaged.
5. Optionally measure moral injury with the Moral Injury Outcome Scale (MIOS; 14 items, past-month agreement). It covers changes in self- and other-perception, moral thinking, social functioning, emotions, self-harm or self-sabotage, and meaning [source: Litz StrongStar slides; CDP 2025 outline]. Obtain the scale from its authors; items are not reproduced here.
6. Plan the order of work: exposure for all patients, plus the grief or moral-injury breakout as the formulation indicates [source: health.mil 2026; Darnell et al., 2022].
Example language (illustrative): "Of everything that happened over there, which one comes back the most, or which one do you work hardest not to think about?" / "Was it more that you nearly died, that you lost someone, or that something happened that goes against who you are?"
Watch for: perpetration events hidden behind a 'safer' life-threat story, since shame often delays disclosure [synthesis]. Suicidal ideation linked to self-condemnation should be assessed directly, following your service's risk protocol [synthesis].

4.2 Session 1: introduction, rationale and goals

Purpose / when: Session 1. Builds alliance, rationale and motivation [source: NCT01628718; book ch. 6].
Steps:
1. Explore who the person was before deployment and how they are now.
2. Give psychoeducation on combat and operational stress injury: stress injuries are injuries, not weakness. Introduce the three harm types.
3. Explain 'adaptive disclosure'. Telling the story fully, in the room, tests the fear that remembering will lead to losing control or to being judged. It also brings to the surface the conclusions the person has drawn about themselves and the world [source: NCT01628718; Darnell et al., 2022].
4. Use motivational interviewing to clarify the change the person wants at work, at home and inside themselves.
5. Give the impact-statement homework (4.3).
6. In the 2009 model, this phase also frames avoidance and concealment as costly. They narrow life and block corrective experiences [source: Litz et al., 2009, step 2].
Example language (illustrative): "You've carried this alone for a long time. What we do here is go back into it together, slowly enough that you stay in charge, so we can look at what it has come to mean about you." / "If this treatment worked, what would be different at home in three months?"
Watch for: ambivalence about speaking at all, and worry about career consequences. Discuss the limits of confidentiality up front [synthesis].

4.3 Impact statement (homework after Session 1, reviewed each session)

Purpose / when: Assigned in Session 1 and reviewed at the start of Sessions 2–7 [source: NCT01628718]. Its content and format are not described in the protocol, the published 2021 trial report, the DoD reports or the pilot summary. Only the manual and its reproducible forms would settle it [uncertain].
Steps [synthesis, modelled on the source's stated purpose]:
1. Ask the person to write how the event has affected their view of themselves, other people, the military and the future, and what they now do differently.
2. Read it together in the next session and mark the strongest conclusions as targets for processing.
Example language (illustrative): "Write a page on how that day has changed you: what you believe about yourself now, about people, about what comes next."
Watch for: avoidance, such as not completing it or writing it in generalities. Treat this as information about the avoided meanings, not as failure [synthesis].

4.4 Imaginal emotional processing (the trauma narrative)

Purpose / when: Core of Sessions 2–7 for every patient. Evokes the emotions and beliefs linked to the event so that unacknowledged interpretations surface, and disconfirms the fear that disclosure leads to 'going crazy' or rejection [source: NCT01628718; Darnell et al., 2022]. The 2021 trial report describes the imaginal narrative as a vehicle to uncover and disclose unacknowledged aspects of the trauma and its meaning, not as a way to extinguish conditioned fear [source: Litz et al., 2021].
Steps:
1. Agree the target event and the starting point.
2. Invite a real-time, sustained recounting of the event, eyes closed if that helps [source: Litz et al., 2009, step 3]. Present tense and first person are the usual exposure convention [uncertain: not confirmed in the AD sources used here].
3. Be directive. Encourage, prompt and cue the person toward the painful elements, including sensory detail, what they did, what they felt and thought, and the moment it 'hit' [source: Litz et al., 2009]. Let the patient set limits [source: NCT01628718].
4. Expect gradual disclosure. Accept a partial account early on and go further in later sessions [source: Darnell et al., 2022].
5. During peaks of emotion, ask what the person is telling themselves at that moment, so the meaning can be caught 'hot' [source: Darnell et al., 2022].
6. In the 2009 model, run exposure every session at first, then shorten it once the person can reach the meanings without a full reliving [source: Litz et al., 2009]. No available source gives the manual's exposure duration per session: the protocol, the published 2021 trial report, the DoD reports and the pilot summary are all silent on it [uncertain]. Keep it within the 90-minute session, leaving time for processing and closure (4.6) [synthesis].
7. For pure life-threat events, Darnell et al. (2022) allow a more habituation-oriented emphasis. The 2021 trial report puts it differently: even for danger-based trauma, the main change agent is modifying 'hot' cognitions through the experience of disclosure, not fear extinction. How the manual reconciles the two is [uncertain]. For loss and moral injury, move into processing and the breakouts [source: Darnell et al., 2022; Litz et al., 2021].
Example language (illustrative): "Take me back there. Where are you standing? What do you see?" / "Stay with that moment... what are you doing right now?" / "What's going through your mind as you see him?" / "You can slow down, but try not to skip that part."
Watch for:
- Skipping or 'fast-forwarding' through hot spots, or a flat, reportorial voice. Prompt gently back to the moment.
- Dissociation (blank stare, delayed answers, feeling unreal). Pause the narrative and ground the person (4.6) before resuming [synthesis].
- Signs it is working: emotion appears and the person stays in contact; new details or meanings emerge; disclosure becomes fuller across sessions; the person reports less fear of the memory [synthesis based on stated aims].
Safety: obtain consent to exposure each session. Exposure is contraindicated for anyone screened out above. Re-assess suicide risk when self-condemnation intensifies [synthesis].

4.5 Processing meaning and implications

Purpose / when: Straight after, and during, the narrative in Sessions 2–7. Identifies extreme or unhelpful appraisals and develops more adaptive ones, using cognitive or experiential techniques [source: NCT01628718]. The manual has an appendix titled 'The Meaning and Implication of Key Events'; its content is [uncertain].
Steps:
1. Name the beliefs that surfaced about self, others, the world and the future.
2. Examine their attributions: stable versus temporary, global versus specific, internal versus shared or contextual [source: Litz et al., 2009, step 4].
3. Where self-condemnation is rigid, separate global worth from the specific act. The aim is that the person can hold a flawed self without accepting the act [source: Litz et al., 2009].
4. Allow remorse. Do not excuse the act or argue that it was understandable [source: Litz et al., 2009].
5. If Socratic work stalls, move to experiential methods, such as an imagined conversation with another person (the breakouts, 4.7–4.12) [source: Darnell et al., 2022].
6. Aim for accommodation: the event is part of the person's story but does not define all of it [source: Litz et al., 2009].
Example language (illustrative): "When you say 'I'm a monster', is that about who you are always and everywhere, or about what happened in those few minutes?" / "The guilt tells me you have a conscience. What would it look like to carry this without it running your whole life?"
Watch for: therapist 'yes, but' arguing, which shuts down disclosure. Shift to 'yes, and' [source: Litz StrongStar slides]. Signs of progress include softer language, a less global self-judgment, and new statements about what the person wants to do now [synthesis].

4.6 Session review, grounding and calming

Purpose / when: End of every active session, and at any point when the person is overwhelmed [source: NCT01628718]. The manual's appendix 3, 'Calming and Attention Focusing Techniques' (title verified on the publisher's contents page), but no available source says which techniques it contains [uncertain]. The specific steps below are generic grounding, not the appendix.
Steps [synthesis for specifics]:
1. Leave enough time to close.
2. Ask what the session was like and what the person is taking away.
3. If arousal is still high, use paced breathing, orienting to the room (naming objects, sounds), feet on the floor, and holding a cold or textured object.
4. Check the person is oriented and safe to leave. Agree any contact plan.
5. Set homework.
Example language (illustrative): "Let's come back to the room. Tell me five things you can see right now." / "What stands out from today?"
Watch for: the person leaving dysregulated or planning to drink. Review the coping plan before they go [synthesis].

4.7 Grief breakout: education about traumatic loss

Purpose / when: Sessions 2–7, when the target is a death, usually of a fellow service member [source: NCT01628718].
Steps [synthesis for content]:
1. Normalise grief and explain how traumatic circumstances can block mourning.
2. Explain survivor guilt, and how bonds with unit members can be as close as family bonds.
3. Introduce the dialogue (4.8) and the honouring activities (4.9) as the way forward.
Example language (illustrative): "Grief after a death like this often gets stuck, because the way he died keeps replaying and the goodbye never happened."
Watch for: guilt mixed into grief ("it should have been me"). This may need the moral-injury tools as well [synthesis].

4.8 Imagined (empty-chair) dialogue with the deceased

Purpose / when: The grief breakout, after the loss event has been processed in narrative. Lets the person say what was never said and hear, in their own voice, what the lost person would want for them [source: NCT01628718; Litz StrongStar slides; Litz et al., 2024]. The Gestalt origin is named in DTIC ADA555048.
Steps:
1. Explain the exercise and get consent. Seat the person facing an empty chair, or let them imagine the deceased in the room with eyes closed [synthesis for set-up].
2. The person speaks directly to the deceased, in real time. They say what happened, how the death has affected them, and anything they confess or regret [source: StrongStar slides; Litz et al., 2024].
3. The therapist prompts toward unsaid material.
4. The person then answers in the voice of the deceased, saying how they would respond and what they would want for the person's life. The slides give forgiveness or a call to embrace life as typical content. Optionally the person changes chairs for this [source: Litz et al., 2024; StrongStar slides; chair change is synthesis]. The 2021 trial report describes these as real-time imaginal dialogues with the lost service member, focused on carrying on in a way that honours the fallen; a common theme is that living well is the best way to honour them [source: Litz et al., 2021; DTIC AD1105420].
5. The therapist may help shape the dialogue [source: Litz et al., 2024].
6. Debrief: ask what it was like and what the person will take from it. Repeat across sessions if needed. AD-E develops the dialogue over several sessions [source: Litz et al., 2024; debrief questions from Litz et al., 2009].
7. Link it to honouring activities and to re-engaging with family and community [source: StrongStar slides].
Example language (illustrative): "He's here now. Tell him what happened after he was hit, and what it's been like since." / "Now sit in his place. What does he say back to you? What would he want for you?"
Watch for:
- If the imagined reply is condemning, ask what the person knew of the deceased's character, and whether the voice sounds like him or like their own guilt [synthesis].
- Embarrassment at 'talking to a chair': offer the eyes-closed version, or the letter alternative from AD-E (4.15) [synthesis].
- Signs it is working: tears or release followed by calm, a more compassionate imagined reply, and spontaneous plans to honour the person [synthesis].

4.9 Honouring the dead (planning and homework)

Purpose / when: Grief breakout. Turns grief into continuing connection and meaningful action [source: NCT01628718; Darnell et al., 2022].
Steps:
1. Ask how the person could honour the deceased.
2. Choose concrete, doable acts. Examples: contact the family, visit the grave (cited in AD-E as an intense extrasession activity), mark the anniversary, take up something they cared about, or live in a way they would respect [source: Litz et al., 2024 for the grave visit; other examples are synthesis].
3. Schedule the act and review it at the next session.
Example language (illustrative): "What is one thing you could do this month that he would recognise as being for him?"
Watch for: contact with the family can be emotionally risky. Rehearse it first [synthesis].

4.10 Moral-injury breakout: education about moral injury

Purpose / when: Sessions 2–7, for perpetration, failure to prevent, witnessing or betrayal [source: NCT01628718; CDP 2025 outline].
Steps:
1. Define moral injury as lasting changes in self- and other-perception, moral emotions, social behaviour and meaning, following a violation of deeply held moral beliefs [source: CDP 2025 outline].
2. Frame guilt and shame as signs of an intact conscience [source: StrongStar slides].
3. Explain that the path is repair and rebalancing goodness, not erasing the memory [source: StrongStar slides].
4. Present shameful material as something that can be shared without condemnation [source: Litz et al., 2009, step 2].
Example language (illustrative): "The fact that this still eats at you tells me your moral compass works. The work here isn't to talk you out of that. It's to find a way to live with it that adds some good back."
Watch for: anger at leaders or institutions in betrayal cases. Dialogues can address others' transgressions too [source: Litz et al., 2024].

4.11 Imagined dialogue with a compassionate (benevolent) moral authority

Purpose / when: The moral-injury breakout, after the event has been disclosed. A modified empty-chair exercise that promotes forgiveness and points the way to repair [source: Litz et al., 2009, step 5; Darnell et al., 2022; Litz et al., 2024]. Procedural detail below comes from the 2009 precursor model, the AD-E description and the 2021 trial report, which calls these dialogues "akin to secular confessions" that challenge guilt, shame and condemnation of self and others [source: Litz et al., 2021]. The manual's own script is not reproduced here [uncertain].
Steps:
1. Choose the figure. Someone who has always been on the person's side, such as a parent, grandparent, coach or clergy member. In AD-E this is identified during the compassion-history assessment [source: Litz et al., 2009; Litz et al., 2024].
2. Fallback if no one fits: the person speaks to an imagined service member they care about who believes himself irredeemable, and gives him advice [source: Litz et al., 2009].
3. Confession. The person tells the figure, in real time, what they did or failed to do. They say how they explain it, how they feel, what they think should happen to them, their remorse, and any wish to make amends [source: Litz et al., 2009].
4. Response. The person then says what the figure would answer. The therapist may introduce forgiveness-related content tailored to the case. Later sessions move toward the figure's guidance on how to go on [source: Litz et al., 2009; Litz et al., 2024]. The 2021 trial report specifies that, after disclosing, the person is asked how the figure reacts to what they have just said, and in later sessions what the figure would say about how they should proceed. Typical themes it reports: for the person's own transgressions, alarm and disappointment paired with a mandate to make amends and to place the event within a good life; for betrayal by others, anger and solidarity paired with a wish that the person move on and let goodness into their life [source: Litz et al., 2021; DTIC AD1105420].
5. Debrief. Ask what that was like and what the person will take from it [source: Litz et al., 2009]. Repeat over sessions if needed.
Example language (illustrative): "Your grandmother is sitting here. Tell her exactly what happened in that compound, and what you think you deserve now." / "Now be her. She's heard all of it. What does she say?"
Watch for:
- A figure who condemns. Ask whether that is truly how this person would respond, or choose another figure [synthesis].
- Premature or glib forgiveness. Slow down and return to the remorse [synthesis consistent with Litz et al., 2009].
- Signs it is working: a shift from self-condemnation to responsibility plus compassion, and ideas for repair emerge [synthesis].

4.12 Making amends or moving on (reparation planning)

Purpose / when: The moral-injury breakout and the following homework. Restores a sense of goodness through action [source: NCT01628718; Litz et al., 2009, step 6].
Steps:
1. Frame amends as changing how one lives from now on. It is not a duty to 'right' an often irreparable wrong [source: Litz et al., 2009].
2. Generate concrete, doable acts with the person, such as service, volunteering, caring for others in need, or repairing harm where that is possible [source: Litz et al., 2009; NCT03056157; Litz et al., 2024].
3. Schedule the acts and review them.
4. Help the person draw a firm line around the past so it does not define the present [source: Litz et al., 2009].
Example language (illustrative): "You can't undo that day. What you can do is decide what kind of person you'll be from here. What would that look like this week?"
Watch for: penance that turns punitive or all-consuming [source: Litz et al., 2009]. Plans to contact victims directly need careful legal, safety and ethical review first [synthesis].

4.13 In vivo exposure to avoided stimuli (homework)

Purpose / when: Hypervigilance and fear-based avoidance, especially for life-threat events [source: NCT01628718; Darnell et al., 2022].
Steps [synthesis for detail]:
1. List avoided situations (crowds, driving, news, reminders) and rank them by difficulty.
2. Agree weekly practice, staying until anxiety eases.
3. Review at the next session.
Example language (illustrative): "Which place have you been steering around that you'd like back?"
Watch for: safety behaviours, such as scanning or carrying an exit plan, that blunt the learning [synthesis]. Do not set exposure to situations that are objectively dangerous [synthesis].

4.14 Reconnection (graded re-engagement and disclosure decisions)

Purpose / when: Mid to late treatment. Counters shame-driven withdrawal and rebuilds roles [source: Litz et al., 2009, step 7; NCT01628718 'social reattachment'].
Steps:
1. List the important people and groups in the person's life. Rank them by expected difficulty and approach them gradually.
2. Help the person decide what to share and how to say what they need. Clarify that they are not responsible for how others react.
3. Prepare for awkward or unhelpful responses before therapy ends.
4. Where relevant, explore faith or spiritual communities as sources of meaning and forgiveness. Note that punitive religious beliefs are linked to worse outcomes. [source: Litz et al., 2009]
Example language (illustrative): "Who is easiest to start with? What's one thing you'd want your wife to understand, without having to tell her everything?"
Watch for: pressure to disclose everything to everyone. The person decides [source: Litz et al., 2009].

4.15 Final session: ending treatment and planning for the long haul

Purpose / when: The last session (Session 8 in the trial version) [source: NCT01628718; book ch. 9].
Steps:
1. Review progress and the lessons learned, highlighting positive ones [source: TraumaPsychNews review].
2. Ask what the person takes from therapy and restate their values and goals [source: Litz et al., 2009, step 8].
3. Name the areas for continued work: triggers, self-care, and social reattachment and re-engagement [source: NCT01628718].
4. Anticipate times when the moral injury moves back to the foreground (anniversaries, news, losses) and plan responses. Agree how to seek booster help [source: Litz et al., 2009; booster detail is synthesis].
5. Invite the person to see growth from their service, where they genuinely do [source: Darnell et al., 2022].
Example language (illustrative): "When the anniversary comes round and it all floods back, what will you do, and who will you call?"
Watch for: symptoms still in the clinical range despite real gains in function. This happened in a published AD case. Plan continued care rather than treating it as failure [source: Darnell et al., 2022 on Laifer et al., 2015].

4.16 Adapting AD when prior complex trauma is present

Purpose / when: Patients with childhood or other cumulative trauma before deployment. The manual has a chapter titled 'Using Adaptive Disclosure when Prior Complex Trauma is Present' (ch. 10; title verified on the publisher's contents page). No available source describes its contents, so the steps below are not the manual's [uncertain].
Steps [synthesis]:
1. Map pre-military trauma during assessment.
2. Keep the war event as the target unless earlier material dominates.
3. Watch for the moral-authority figure overlapping with an abuser, and choose another figure if so.
4. Allow more stabilisation time and slower graded disclosure.
Watch for: dissociation and self-harm urges. Consider a phase-based trauma treatment if stabilisation is insufficient [synthesis].

AD-E components (12-session variant; Litz et al., 2024)

4.17 Compassion-history assessment

Purpose / when: Session 1 of AD-E. Guides planning: which behaviours the person could reclaim, and who could serve as a compassionate moral authority. Revisited in the final session to discuss changes in compassion [source: Litz et al., 2024].
Steps [synthesis for detail]:
1. Ask about times the person received and gave care and kindness, before and since deployment.
2. Ask what they used to do for others that they no longer do.
3. Ask who in their life embodies forgiveness and kindness.
Example language (illustrative): "Who has shown you kindness when you didn't feel you'd earned it?" / "What did you used to do for other people that you've stopped doing?"
Watch for: a person who says no such figure exists. Use the fallback in 4.11.

4.18 Loving-kindness meditation (LKM) and mindfulness

Purpose / when: Introduced in Session 1 of AD-E and the focus of at least three later sessions, with handouts and practice. Targets guilt, shame, resentment, and contempt for self and others, and builds a sense of shared humanity [source: Darnell et al., 2022; Litz et al., 2024; StrongStar slides].
Steps:
1. Teach brief mindful attention.
2. Guide repetition of well-wishing phrases, directed in turn to a loved one, the self, a neutral person, and difficult others including the self who did harm. The order follows the common LKM sequence [uncertain: not confirmed for AD-E].
3. Address barriers, such as feeling undeserving.
4. Assign daily practice. [source for phrases and barriers guidance: StrongStar slides; Litz et al., 2024]
Example language (illustrative): "Silently offer: may you be safe, may you be at ease. Now try offering the same to yourself, even if it feels false."
Watch for: intense shame or grief when wishing well to the self. Slow down and normalise this. Mindfulness can trigger intrusions in some people with PTSD, so keep eyes open and anchors external if needed [synthesis].

4.19 Serial letter writing

Purpose / when: Assigned between most sessions from 2 to 10 in AD-E. A complement or alternative to live dialogue [source: Darnell et al., 2022; Litz et al., 2024].
Steps:
1. Letter 1 discloses or confesses the event to the harmed person, the lost person, or a compassionate moral authority. Write the specific details of what happened [source: Litz et al., 2024; StrongStar slides].
2. A later letter describes the lasting negative impact.
3. A later letter is written back to the person in the voice of the compassionate moral authority or the lost person, giving forgiveness, feedback or guidance.
4. Letters include a plan for repair and healing [source: StrongStar slides].
5. The person reads each letter aloud in session and processes it.
Example language (illustrative): "This week, write to him as if he could read it. Say exactly what happened, not the cleaned-up version."
Watch for: letters written in a vague or intellectual way. Ask for concrete detail. Letters are never to be sent to real victims without separate careful review [synthesis].

4.20 Healing and Repair Plan (shared-decision behavioural contracting)

Purpose / when: Throughout AD-E. Structures between-session corrective experiences that produce functional change [source: Litz et al., 2024; Darnell et al., 2022].
Steps:
1. Build a master list together, organised under three headings:
  - behavioural activation and self-care;
  - in vivo exposure;
  - thematically corrective or repair activities (amends, volunteering, caring for others, reconnecting).
2. Choose items by the person's preference and the likelihood of success.
3. Contract specific weekly assignments, emphasising work, relationship and family roles.
4. Rate completion (completed or partially completed) and adjust.
5. The core procedure is daily reparative activity aimed at restoring faith in humanity and rebuilding valued connections [source: CDP 2025 outline].
Example language (illustrative): "Let's pick two things from your list for this week: one that looks after you and one that puts something good back into the world."
Watch for: plans that are too large. Shrink them until success is likely [synthesis].

4.21 Skills training and behavioural contracting for role functioning (AD-MIL)

Purpose / when: In AD-MIL, targets the psychological and behavioural obstacles to occupational, relationship and family roles. Homework for moral injury includes reparative volunteering and spiritual or meaningful practice. Homework for loss includes restoring attachments and wellness behaviours. Homework for life threat includes valued activities that counter fear-driven avoidance [source: NCT03056157].
Steps: The specific skills modules are not described in the AD-MIL protocol, and no other published description of them is drawn on [uncertain]. Use the contracting procedure in 4.20.
Watch for: the same issues as in 4.20.

5. Handling problems

The available sources say little about troubleshooting. Each item below is marked as sourced or [synthesis].

Rigid sequencing leads to non-adherence or dropout. The developers found that a fixed serial order of change agents often led to failure or dropout in patients who struggled to comply, and built AD-E's shared-decision Healing and Repair Plan in response [source: Darnell et al., 2022]. Response: let the person choose the next change agent, shrink assignments, and use letters if live dialogue is refused. About a quarter of pilot participants dropped out [source: Gray et al., 2012 summary].
Partial or evasive disclosure. Expected. Disclosure is graded across sessions [source: Darnell et al., 2022]. Response: accept the partial account and name the gap without pressure. Return to it later: "There's a part you step around each time. We don't have to go there today, but I notice it" (illustrative) [synthesis].
Overwhelm or dissociation during the narrative. The patient sets limits [source: NCT01628718]. Response [synthesis]:
1. Pause the narrative and switch to eyes open.
2. Ground the person (4.6).
3. Resume at lower intensity or move to processing.
4. Never end the session while the person is dissociated.
5. If it recurs, give more stabilisation sessions or use the letter format.
Suicidality rising with self-condemnation. Trials excluded people with recent serious suicidality and kept 24-hour crisis access and referral to higher care [source: NCT01628718; NCT03056157]. Response: assess risk each session when moral-injury work is active, keep a written safety plan, and counsel on safe storage of lethal means, firearms especially. Pause disclosure work if risk escalates [synthesis].
Therapist reactions (disgust, fear, urge to absolve, detachment). The source advises preparing in advance, because visible revulsion reads as condemnation and quick absolution invalidates the person [source: Litz et al., 2009]. Therapists may find it hard to sit with the existential reality of moral harm [source: StrongStar slides]. Response: use supervision, slow your own pace, and come back to 'yes, and' [synthesis].
'Yes, but' standoffs. When cognitive challenge meets "but I did kill him", stop persuading. Accept the fact of responsibility and move to experiential work (dialogue, letters) and repair [source: StrongStar slides; Darnell et al., 2022].
The imagined authority or the deceased condemns the person. Response [synthesis]:
1. Ask whether the voice reflects the real person or the person's own guilt.
2. Ask what that figure actually did when others erred.
3. Switch figures, or use the advice-to-a-comrade fallback [source for fallback: Litz et al., 2009].
Feeling silly with empty-chair work. Normalise it, offer eyes-closed imagery or letters, and start with a brief exchange [synthesis].
Penance becomes self-punishment. Re-frame amends as living differently from now on, not repaying a debt. "Draw a firm line around the past" [source: Litz et al., 2009].
Disclosure with legal implications (possible war crimes, ongoing harm). Before exposure, explain the limits of confidentiality under your jurisdiction and service rules, including military duty-to-report rules for active-duty patients. Do not dig for facts. If a disclosure triggers a mandatory duty, consult and document [synthesis].
Betrayal by leaders or institutions (others' transgressions). Dialogues can be directed to the transgressor, or to a moral authority about others' acts [source: Litz et al., 2024]. Repair work then focuses on restoring trust in good people and reclaiming values [synthesis].
Unhelpful responses from family or friends after disclosure. Prepare for them in advance, and remind the person they are not responsible for others' reactions [source: Litz et al., 2009].
Punitive religious beliefs. These are linked to worse outcomes. Response: explore them respectfully, consider consulting a chaplain with the person's consent, and look for forgiveness themes within their own tradition [source: Litz et al., 2009 for the link; response is synthesis].
Residual symptoms at the end despite functional gains. Plan continued care and booster sessions [source: Darnell et al., 2022, citing Laifer et al., 2015; booster is synthesis].
Substance use flare during treatment. Trials excluded active substance-use disorders. Response: set a plan for no use around sessions, and pause exposure if use escalates or the person attends intoxicated [synthesis].
Non-military or civilian moral injury (first responders, healthcare staff). AD was built and tested for military populations. Adapting it is a [synthesis] decision. Replace the military-culture content with the culture of the person's own profession.

Temporary worsening early in treatment. In the 2021 trial, therapists prepared patients for possible short-term worsening and monitored symptoms with them [source: Litz et al., 2021]. Response: forewarn the person in Session 1 that disclosure can raise distress for a while, and review symptom ratings together each session [synthesis for the wording].
Unclear whether to continue or change focus. The trial authors recommend rating PTSD and depression before every session and deciding jointly with the patient when to shift focus [source: Litz et al., 2021]. Response: if scores climb or stay flat over several sessions, discuss changing the target event, the change agent, or the format (for example, letters instead of live dialogue) [synthesis].

Sources

Sources used:

Books and papers cited (contents or citations only):

Litz, B. T., Lebowitz, L., Gray, M. J., & Nash, W. P. (2016; cited as 2017). Adaptive Disclosure: A New Treatment for Military Trauma, Loss, and Moral Injury. Guilford Press. Known here from the publisher's contents and reproducible-materials pages.
Gray, M. J., et al. (2012). Adaptive disclosure: An open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behavior Therapy, 43(2), 407–415. Cited through the REACH summary (six 90-minute sessions delivered by four PhD psychologists; 25% of starters dropped out).
Steenkamp, M. M., et al. (2011). A brief exposure-based intervention for service members with PTSD. Cognitive and Behavioral Practice, 18, 98–107.
Litz, B. T., et al. (2024). Supplemental materials to the AD-E trial, Journal of Consulting and Clinical Psychology (APA, ccp0000873) [uncertain].
Laifer, L. M., et al. (2015), AD case study, as cited in Darnell et al. (2022).

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